Rate response.

I'm two months post implant on a Biotronik Edora 8 DR-T for SSS from taking metoprolol for AFib with resulting bradycardia. I'm actually Brady/tacky. I acknowledge I still know very little about the pacemaker settings. I tried to ask as many questions as I can but at an interrogation yesterday, I noted the device nurse didn't really seem to know a lot. I do get a printout every time.

I learned most from the posts and researching previous posts. I noted in the archives that there have been numerous discussions about turning off the rate response. I asked yesterday if mine is on and they said yes.I don't know enough to even know what to ask beyond that, but I asked what those settings were and the device nurse didn't say too much.

I'm asking this because I feel like I'm doing great except for two circumstances. I get short of breath going up a hill and going up a flight of stairs. I noticed in the archives that that was a common problem, but the posts I read were probably 10 years old. I'm wondering if that problem has been improved in the pacemakers themselves over that period of time. Posters recommended swinging arms and breathing more rapidly to trigger the PM (I guess,).I did so today but felt it intensified the climb  but didn't alleviate the SOB. My pulse on a hill is about 110-128 consistently. Prior to the PM, at times my pulse didn't exceed 85 or 90 on a hill and I felt pretty bad.

I'm wondering if I should request the RR be turned off.

This is all I could decipher on the readout regarding this:

Sensor/rate fading (bpm) 110/---U

Upperrate response (bpm) 120/WKB 

Mode switching (bpm).    160/DDIR 

Pacing A/V (%}  84/0

Thanks for any feedback. I will have another interrogation and see the EP in 6 mos. unless I request a specific appointment.


8 Comments

Atrial Fibrillation (AF) and Metoprolol

by Gemita - 2021-01-13 16:38:57

https://www.pacemakerclub.com/message/690/shortness-of-breath-sob

Dear Pharnowa, 

I think there are two questions to your post to be answered:

1) is the problem related to pacemaker settings alone or

2) is the problem related to your Metoprolol and arrhythmia AF affecting your ability to get enough air into your lungs as you try to exert yourself going uphill or upstairs.  If your AF is not yet under control, I believe this could be a strong cause for your symptoms of SOB.  It certainly is for me when I climb stairs or hills in AF and the higher your heart rate goes, the worse your SOB.

Did your clinic by chance tell you the percentage time you spent in AF or other arrhythmias?  They will have this information.  If not, I would get this information from them.  Did they change your medication or increase dosage of Metoprolol?

The pacemaker cannot cure AF and in my opinion if AF is the problem, it is important to get that under better control first since it may affect whatever settings they decide to adjust.  

I am disappointed you didn’t get a good feeling about your pacemaker check and that questions remain unanswered.  On your settings, I can see this is only a very brief list of your total settings, but I will endeavour to answer what I can.  You appear to be 84% atrial paced.  Your mode switch for AF is set at 160 bpm at which rate mode switch to DDIR mode will activate.  This is a non tracking mode on detection AF.  This occurs when rate and duration of AF meet the criteria set up in your pacemaker to trigger a mode switch so as not to track your AF.  It switches back to your normal mode on cessation AF.  My RR is on and generally I have no difficulty going upstairs or uphill EXCEPT when I am in AF.  My upper rate is set at 130 bpm. I see yours is at 120 bpm which might be a bit low as you try to climb stairs.  You could ask whether this could be safely raised to 130 bpm with AF?

I attach an old PM Club link above on the definition of SOB which I feel is very helpful so you can see how many of us have the same difficulties.  You are progressing and it will get better.  It took me, my AF, my heart and my pacemaker at least three months to settle.  I noticed an increase in SOB initially.  You have nothing to lose to ask them to turn off RR to see how you might manage without it 

Biotronik RR = CLS

by Persephone - 2021-01-13 17:30:57

Hi Pharnowa - I've got the Biotronik Eluna rather than the Edora, but assume that our two devices run similar RR programs.  The Biotronik RR model is called Closed Loop Stimulation (CLS) and is in theory supposed to provide more adaptive response to the need for increased heart rate, compared to an accelerometer-based RR system.  An accelerometer-based RR may require the arm waving and foot stomping that you refer to under certain conditions, but CLS is supposed to learn what you need based on your activity level, and provide it when you need it.

I dealt with continued SOB on exertion similar to what you describe - granted much less than pre-implant - for about a year until I asked my doc for a stress test.  The Biotronik rep attended and made adjustments that made me much more comfortable and able to do what I wanted to do.  You may want to consder asking for a stress test if your device's CLS isn't providing what you need it to.

Thanks Gemita and Persephone,;

by Pharnowa - 2021-01-13 22:01:57

I appreciate the in depth responses!

Gemita my AFib was 1%, 3 events in a month. I don't know how long an event has to be before it's recorded as an event. My uphill climb is about 5 to 6 minutes almost daily. Since I have experienced annoying vibration in my throat during afib since I got the PM, and I'm not experiencing that on these climbs, I tend to think the shortness of breath going up the hill is not what is happening. Frankly, I always sit down when I get AFib, but since I lately usually get tachycardia with it, and my HR can be quite high, approaching and even over 200, I can't imagine going up a hill at that time.

Thanks for the link and the ongoing reassurance. I will ask about turning off the RR. The EP said my coloring is good so I must be benefiting from the oxygen the extra 20 bpm resting HR provides.

Persephone, thank you for explaining CLS. I'm glad there is no need to swing my arms as it was exhausting. :)  When I understand that others have periods of SOB, I really do appreciate how well I've done. I can't complain.

I do feel I've had more AFib since implantation and I wonder if the process has irritated my heart and left at least a temporary increase.

Thank you again.

 

 

Possible action plan

by Gemita - 2021-01-14 01:44:00

Yes Pharnowa I had an immediate deterioration in my arrhythmias following my pacemaker implant which did worry me at first until I realised that this could be a perfectly normal response because my heart had been traumatised by lead attachment and by the whole procedure in general. In fact for several months I kept getting new waves of tachycardia which if they occurred during any form of exertion, I would feel short of breath.

I like what Persephone has written and could well be the answer for you too and I would follow her advice and ask your doctor about this possibility.

Your percentage 1% in AF seems good but remember that this figure may not fully reflect the total number of episodes you are getting - say, any short, in and out episodes.  A good way of finding out how many episodes you are getting would be to ask how many AMS (automatic mode switches) are occurring over say a month.  I expect the mode switch count is considerably higher than the recorded 3 episodes per month.  This figure is good to know because if like me your percentage AF burden is low but your AMS  switches are regularly occurring (for example I had several thousands of them occurring over one year), you will realise that you are getting more episodes of AF than the 1% figure might suggest, or certainly more than 3 episodes in a month.  If on the other hand your AMS switches are low, closely reflecting only 3 episodes a month, then this might indicate your episodes are less frequent but perhaps longer lasting when they occur.

You would ideally have to ask your doctors what has been set up in your pacemaker to trigger an Automatic Mode Switch, say a heart rate exceeding 160 bpm for "X" number of beats, but only they can tell you.

So you seem to think you are not in AF when going uphill because you usually get throat vibration during AF and you are not getting it everytime you go uphill, nor would you even be able to go uphill while in AF due to high heart rates.  Did you tell your pacemaker technicians and did they check for any significant events/high heart rates?  High heart rates approaching 200 bpm would definitely be flagged as significant.  I wonder if Metoprolol is effective for you?  So when in AF you would need to sit down.  That suggests to me your heart rate during significant AF episodes is not being effectively controlled.  I can usually keep going in AF unless my heart rate is too high.  

Action plan:  I would make sure your EP knows about your symptomatic AF episodes and continuing high heart rates.  I would ask about the CLS adjustments as Persephone suggests.  I would ask for the total Automatic Mode Switch figures.  I would also ask about RR changes but whatever pacemaker adjustments you make do them slowly since everything may settle in a few months without any intervention !  

Atrial fibrillation and metoprolol

by Selwyn - 2021-01-14 08:25:08

I see you have a similar problem to my post of last week ( 05/01/2021) concerning shortness of breath on starting to exercise.

I did have my resting heart rate increased following a discussion with my pacemaker tech.  

Beta blockers can be a real pain for exercise and in effect cause shortness of breath as they keep your heart rate low (hence in your case I believe you had bradycardia- a low heart rate and needed a PM).  

I would suggest you try a different beta blocker or seek an alternative mode of action drug to control your AF. Personally, I had to stop beta blockers as I could only swim 3/4 of a length when I should be swimming a mile. Flecainide was much better for me though caused atrial flutter ( Bad news!) 

Turning off the rate response is not going to help and may make the situation worse.

You will see from my post of last week that we are still troubled by shortness of breath on starting to  exercise. This is especially bad with cycling as the rate response does not pick up very well, no matter what sort of PM you have (I am told). 

About RR

by Gotrhythm - 2021-01-14 16:21:31

With little experience of medications, I have only two points to add to this discussion.

1. In most places, the pacemaker tech isn't really able to answer any questions about your pacemaker or functions. All he/she can tell is if the pacemaker is working the way it's programmed to. Wanting the tech to change settings is like expecting the pharmacist to alter your prescription.

2. Rate response is more than just Off/On. It can be made more and less sensitive. In other words, if RR is on, there are also RR settings that govern how fast or how gradually it will speed up your heart rate. Which setting you will tolerate best is an individual matter.

Again, a change in RR needs to be discussed with your doctor.

RR

by AgentX86 - 2021-01-14 22:36:43

My device tech changes my RR settings pretty much at my request.  She doesn't change the rates but will change the sensitivity, dwell, and slope.  I was just there a few weeks ago and had her increase the sensitivity.  She then passes the settings off to an EP for review.

 

As Agentx86 has said- if you speak with knowledge, they will customize for you

by jds66 - 2021-01-15 09:01:18

And, that is why you are probably here, to gain knowledge. My EP and Medtronic rep has worked with me, in getting my settings right, letting me run in place in the office, do some stairs in the building to get the heart rate up, make some changes, do it again, etc. 

The settings my EP has full confidence in my suggestions are the ones that pretty much wont hurt me- so he lets me, based on my years with him in office and demonstrating good knowledge of my device, suggest changes. 

Suggesting a different sensitivity for rate response is very OK to ask for. They cannot feel what your heart is doing, but if you simply just start walking in place while at the interrogation, and tell them that you are uncomfortable, they will be able to see how much your heart is reacting to that simple motion. These are things they should be happy to work with you on. 

I also am "allowed" to tell the EP and Medtronic tech where I want my low rate. I know what works for me, and they let me experiment- they want me well, so it benefits all. 

Learn your device, you can actually download the device manual, and I am talking the REAL device manual with in depth comments about all the setting choices from the manafacturer. 

Once you establish that you have some knowledge, they are going to work with you. Dont worry, they wont let you change things that they know are going to wipe you out, or things that would jeaporadize their medical license- they are smarter than that. 

PS-both my EP's have told me they wish they could give me a programming device to take home, so I could do my tests. I considered that a compliment! (and, do not expect that your EP knows more about the device than the Manafacturer rep that comes to do the settings changes- the EP is good at putting things in, like pacers and leads, but knowing how to program that device, you would be surprised, they dont know as much as you think)

You know you're wired when...

Your device acts like a police scanner.

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